Provider Demographics
NPI:1497849186
Name:ALBUQUERQUE I.H.S. DENTAL CLINIC
Entity Type:Organization
Organization Name:ALBUQUERQUE I.H.S. DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CORDOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-922-4248
Mailing Address - Street 1:P.O. BOX 67830
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87193
Mailing Address - Country:US
Mailing Address - Phone:505-346-2306
Mailing Address - Fax:
Practice Address - Street 1:9169 COORS ROAD, NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120
Practice Address - Country:US
Practice Address - Phone:505-346-2306
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ846024Medicaid
NM89730Medicaid